Provider Demographics
NPI:1265413918
Name:ANDERSEN, LYLE MELVIN (PT)
Entity type:Individual
Prefix:
First Name:LYLE
Middle Name:MELVIN
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1917 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-2704
Mailing Address - Country:US
Mailing Address - Phone:209-549-4626
Mailing Address - Fax:209-549-4625
Practice Address - Street 1:1917 COFFEE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2704
Practice Address - Country:US
Practice Address - Phone:209-549-4626
Practice Address - Fax:209-549-4625
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT5278225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PT52780Medicaid
CA00PT52780Medicare ID - Type Unspecified
R26873Medicare UPIN